Rhinitis - Allergic (1 of 15) 1 Patient presents w/ signs & symptoms of rhinitis 2 • Consider other classifi cations of rhinitis DIAGNOSIS No - Please see Rhinitis Is allergic rhinitis - Nonallergic disease confi rmed? management chart Yes 3 ASSESS DURATION & SEVERITY OF ALLERGIC RHINITIS A Non-pharmacological therapy • Allergen avoidance • Patient education VAS <5 VAS ≥5 B Pharmacological therapy B Pharmacological therapy • Antihistamines (oral/nasal), &/or • Corticosteroids (nasal), w/ or without • Corticosteroids (nasal), or • Antihistamines (nasal), or • Cromone (nasal), or • LTRA • Leukotriene receptor antagonists (LTRA)MIMS TREATMENT © See next page Specifi cally for patients w/ asthma Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B167 © MIMS Pediatrics 2020 Rhinitis - Allergic (2 of 15) Previously treated symptomatic Previously treated symptomatic patient (VAS <5) on antihistamines patient (VAS ≥5) on intensifi ed (oral/nasal) &/or corticosteroids (nasal) therapy w/ corticosteroids (nasal) w/ or without antihistamines (nasal) Intermittent Persistent symptoms, symptoms or without allergen w/ allergen exposure exposure B Pharmacological therapy B Pharmacological therapy • Step down or discontinue therapy • Continue or step up therapy Untreated REASSESS DISEASE SEVERITY VAS symptomatic patient DAILY UP TO DAY 3 (VAS <5 or ≥5) 4 CONTINUE Yes THERAPY & STEP EVALUATION VAS <5 DOWN THERAPY1 Improvement of symptoms? No VAS ≥5 B Pharmacological therapy • Step-up therapy REASSESS DISEASE SEVERITY MIMSVAS DAILY UP TO DAY 7 4 Yes EVALUATION VAS <5 Improvement of symptoms? No TREATMENT © VAS ≥5 See next page Continue therapy if symptomatic; consider step-down or discontinuation of therapy if symptoms subside Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B168 © MIMS Pediatrics 2020 Rhinitis - Allergic (3 of 15) PATIENTS W/ MODERATE TO SEVERE SYMPTOMS VAS ≥5 • Review diagnosis • Review compliance • Assess for infections or other causes RHINITIS - ALLERGIC Itch/sneeze major Rhinorrhea major Blockage major symptom symptom symptom B Pharmacological B Pharmacological B Pharmacological B Pharmacological therapy therapy therapy therapy • Add or increase • Add antihistamines • Add Ipratropium • Add decongestant corticosteroids (nasal) (nasal) or (nasal) short-term oral corticosteroid Improvement of symptoms? CONTINUE Yes THERAPY & C Immunotherapy No Improvement of Yes symptoms? STEP DOWN THERAPY1 No C Immunotherapy D Surgical therapy Continue therapy if symptomatic; consider step-downMIMS or discontinuation of therapy if symptoms subside. © Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B169 © MIMS Pediatrics 2020 Rhinitis - Allergic (4 of 15) 1 SIGNS & SYMPTOMS OF RHINITIS • Rhinitis: Infl ammation of the nasal lining membranes Major Signs & Symptoms • Nasal itching • Rhinorrhea • Nasal congestion, w/ or without obstruction • RHINITIS - ALLERGIC Sneezing Other Signs & Symptoms • Headache • Conjunctival symptoms, eye pruritus • Pruritus of the nose, palate, ears • Postnasal drainage • Impaired smell 2 DIAGNOSIS Allergic Rhinitis • IgE-mediated infl ammatory disease of the nasal mucous membrane occurring after exposure to allergens & trigger factors • Diagnosis relies primarily on the clinical history & physical exam • Most prevalent in childhood & adolescence • Careful elimination of nonallergic etiologies must be done in preschool children as allergic rhinitis is unusual in <3 years Clinical History • A family or personal history of allergic & related conditions - Asthma - Infantile eczema (atopic dermatitis) - Rhinitis, rhinosinusitis - Recurrent otitis media w/ or without eff usion • Investigate onset patterns of symptoms including triggers & seasonality, & relief w/ certain treatments • Social & environmental history - Exposure to allergens & trigger factors Physical Exam • Detect other diseases (eg asthma, atopic dermatitis, cystic fi brosis, otitis media or eustachian tube dysfunction) which may occur in relation w/ allergic rhinitis Nasal Exam • Can be carried out using a nasal speculum or by endoscopy - Endoscopy is done when symptoms persist despite treatment • May reveal the following: - Swollen nasal turbinates (note size & color) - Rhinorrhea w/ clear, cloudy or colored discharge - Viral infection, sinusitis is considered if colored discharge is noted • Patient should be referred to an ENT specialistMIMS if fi ndings are more consistent w/ a structural etiology than rhinitis (eg tumors, nasal polyps, septal deviation, etc) Other Physical Findings May Include: • Conjunctival injection & edema • Allergic shiners (dark circles under the eyes) • Morgan-Dennie lines (lower eyelid creases) • Periorbital edema • Allergic salute which gives rise to nasal crease • Dental malocclusion • Open-mouth breathing or allergic gape • Cobblestoning© (lymphoid hyperplasia) B170 © MIMS Pediatrics 2020 Rhinitis - Allergic (5 of 15) 2 DIAGNOSIS (CONT’D) Laboratory Studies Allergy Testing • Skin test: Used to diff erentiate allergic from nonallergic rhinitis & to identify the triggering agents • Allergen-specifi c IgE identifi cation corresponding to allergen exposure & symptomatic periods is confi rmatory of allergic rhinitis - Has high sensitivity & specifi city RHINITIS - ALLERGIC • Radioallergosorbent test (RAST) may also be used for the detection of allergen-specifi c IgE - Alternative for patients w/ extensive dermatitis or dermatographism, those at high-risk for anaphylaxis, patients taking drugs that may inhibit mast cell degranulation, & those who cannot tolerate skin test Nasal Smear • Eosinophils in the nasal smear usually indicate allergy; it may support the diagnosis of allergic rhinitis 3 ASSESSMENT • Stepwise treatment approach depends on severity, duration & frequency of allergic rhinitis Symptom Duration of Allergic Rhinitis is Classifi ed into the Following: Intermittent • Symptoms occur <4 days/week or symptoms last for <4 consecutive weeks/year Persistent • Symptoms occur >4 days/week & last for >4 consecutive weeks/year Symptom Severity of Allergic Rhinitis is Classifi ed into the Following: Moderate-Severe 1 or more of the following • Sleep disturbance • Problems w/ functioning at work or at school • Impairment of routine & leisure activities • Bothersome symptoms Mild • Normal sleep • Normal functioning at work & school • Normal conduct of routine & leisure activities • No bothersome symptoms Patterns of Exposure to Allergens: Seasonal • Dependent on a specifi c season Perennial • Year-round allergen exposure & usually present in everyday environment Episodic • Patient is exposed to allergens not normallyMIMS encountered in daily activities © Not all products are available or approved for above use in all countries. Specifi c prescribing information may be found in the latest MIMS. B171 © MIMS Pediatrics 2020 Rhinitis - Allergic (6 of 15) 4 EVALUATION Evaluation of Disease Control • e following factors are considered when evaluating a patient’s response to treatment: - Symptom scores - Measures of nasal obstruction (eg peak nasal inspiratory fl ow, acoustic rhinometry, rhinomanometry) - Allergic Rhinitis & its Impact on Asthma (ARIA) severity classifi cation - Quality of Life (QOL) result - Itemized scoring - Symptom-medication scoring - VAS - A low VAS score w/ the establishment of treatment (<5) shows an amount of improvement, as indicated in Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) as well as in terms of work effi ciency, & treatment is usually maintained or continued - VAS score of <2 means well-controlled allergic rhinitis & treatment is usually stepped down - A high VAS score (≥5) shows no eff ect in symptom relief & treatment is usually stepped up MACVIA-ARIA Sentinel NetworK for Allergic Rhinitis (MASK-Rhinitis) • A clinical approach used to diagnose & classify patients based on disease severity, as well as a tool to evaluate symptom control after initiation of treatment strategies by using Information & Communications Technology (ICT) tools & a clinical decision support system (CDSS) based on ARIA guidelines • Electronic monitoring of allergic diseases include a cell phone-based VAS assessment (uses MASK aerobiology which is a simple IOS/Android app), Control of Allergic Rhinitis & Asthma Test (CARAT), an e-Allergy screening & the RhinAsthma Patient Perspective (RAPP) tool for smartphones A NON-PHARMACOLOGICAL THERAPY Patient Education • Provide general information about the disease & available treatments - Manage the patient’s & caregiver’s expectations from therapy & explain that a complete cure may not be possible • Provide educational materials as necessary • Educate both patient & caregiver about the proper use & timing of medications especially during times when allergen exposure is unavoidable - Possible side eff ects should also be advised - Concomitant medications should also be reviewed to determine if the patient is taking drugs that may cause oral or nasal dryness • Educate the caregiver & the patient, if possible, about the complications of allergic rhinitis (eg otitis media & chronic sinusitis) Allergen Avoidance • Identifi cation & avoidance of trigger allergens should be an integral part of allergic rhinitis management strategy • Removal of the allergen may result in diminished severity of the disease & decreased requirement for